Is it safe to stop taking digoxin in HFrEF patients on beta-blockers?

Patients with heart failure (HF) with reduced ejection fraction (HFrEF) who are taking beta-blockers may discontinue using digoxin without putting themselves at greater risk of adverse outcomes, suggest the results of the OPTIMIZE-HF study. 

At 1 year, digoxin discontinuation among patients on beta-blockers showed no significant association with the combined endpoint of HF readmission or death (hazard ratio [HR], 1.01, 95 percent confidence interval [CI], 0.85–1.19), HF readmission (HR, 1.03, 95 percent CI, 0.85–1.25), and death (HR, 0.91, 95 percent CI, 0.72–1.14). 

Among patients not taking any beta-blocker, digoxin discontinuation resulted in increased risks for the combined endpoint of HF readmission or death (HR, 1.60, 95 percent CI, 1.25–2.04), HF readmission (HR, 1.62, 95 percent CI, 1.18–2.22), and death (HR, 1.43, 95 percent CI, 1.08–1.89). 

“Future studies need to examine the residual benefit of older HF drugs to ensure their safe discontinuation in patients with HFrEF receiving newer guideline-directed medical therapy,” the investigators said.  

In OPTIMIZE-HF, 450 out of 2,477 patients with HFrEF taking both digoxin and beta-blockers discontinued the use digoxin. The investigators assembled a propensity score-matched cohort of 433 pairs of patients in which digoxin continuation vs discontinuation groups were balanced on 51 baseline characteristics. 

From 992 participants not taking beta-blockers, a matched cohort of 198 pairs of patients were also balanced on 51 baseline characteristics using the same method. HRs and 95 percent CIs were estimated at 1 year. 

"National heart failure guidelines recommend quadruple therapy with renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter 2 inhibitors for patients with HFrEF, most of whom also receive loop diuretics,” the investigators said.